MEDICARE: GERALD MICHAEL JACKSON PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	0624	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730221029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD MICHAEL JACKSON PT

Provider Business Mailing Address
First Line	:	2100 E CALVADA BLVD
Second Line	:
City	:	PAHRUMP
State	:	NV
Zip	:	89048-5805
Country	:	US
Telephone Number	:	775-727-7959
Fax Number	:	775-727-7960

Provider Business Practice Location Address
First Line	:	2100 E CALVADA BLVD
Second Line	:
City	:	PAHRUMP
State	:	NV
Zip	:	89048-5805
Country	:	US
Telephone Number	:	775-727-7959
Fax Number	:	775-727-7960

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	11/20/2019

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